Is attention deficit hyperactivity disorder (ADHD) too often confused with immaturity or just young age? It may be, according to new research by a Michigan State University economist published in the Journal of Health Economics.

ADHD is the most commonly diagnosed behavioral disorder for kids in the United States, with at least 4.5 million diagnoses among children under age 18, according to the Centers for Disease Control and Prevention.

Often diagnoses of ADHD depend on a child's age relative to classmates and the teacher's perceptions of whether the child has symptoms, says the new research. Nearly 1 million children in the United States are potentially misdiagnosed with ADHD by the time they kindergarten class, and perhaps just because they are younger than others.

Such inappropriate treatment is particularly worrisome because of the unknown impacts of long-term stimulant use like Ritalin on children's health, says Todd Elder, assistant professor of economics. It also wastes an estimated $320 million-$500 million a year on unnecessary medication – some $80 million-$90 million of it paid by Medicaid, he said.

"If a child is behaving poorly, if he's inattentive, if he can't sit still, it may simply be because he's 5 and the other kids are 6," said Elder. "There's a big difference between a 5-year-old and a 6-year-old, and teachers and medical practitioners need to take that into account when evaluating whether children have ADHD."

Complicating the issue is that there are no neurological markers for ADHD, such as a blood test, making diagnoses even more subjective, and experts disagree on its prevalence, fueling intense public debate about whether ADHD is under-diagnosed or over-diagnosed.

Using a sample of nearly 12,000 children, Elder examined the difference in ADHD diagnosis and medication rates between the youngest and oldest children in a grade. The data is from the Early Childhood Longitudinal Study Kindergarten Cohort, which is funded by the National Center for Education Statistics.

According to Elder's study, the youngest kindergartners were 60 percent more likely to be diagnosed with ADHD than the oldest children in the same grade. Similarly, when that group of classmates reached the fifth and eighth grades, the youngest were more than twice as likely to be prescribed stimulants.

Overall, the study found that about 20 percent – or 900,000 – of the 4.5 million children currently identified as having ADHD likely have been misdiagnosed.

Elder used the students' birth dates and the states' kindergarten eligibility cutoff dates to determine the youngest and oldest students in a grade. The most popular cutoff date in the nation is Sept. 1, with 15 states mandating that children must turn 5 on or before that date to attend kindergarten.

The results – both from individual states and when compared across states – were definitive. For instance, in Michigan – where the kindergarten cutoff date is Dec. 1 – students born Dec. 1 had much higher rates of ADHD than children born Dec. 2. (The students born Dec. 1 were the youngest in their grade; the students born Dec. 2 enrolled a year later and were the oldest in their grade.)

Thus, even though the students were a single day apart in age, they were assessed differently simply because they were compared against classmates of a different age set, Elder said.

In another example, August-born kindergartners in Illinois were much more likely to be diagnosed with ADHD than Michigan kindergartners born in August of the same year as their Illinois counterparts. That's because Illinois' kindergarten cutoff date is Sept. 1, meaning those August-born children were the youngest in their grade, whereas the Michigan students were not.

According to the study, a diagnosis of ADHD requires evidence of multiple symptoms of inattention or hyperactivity, with these symptoms persisting for six or more months – and in at least two settings – before the age of seven. The settings include home and school.

Although teachers cannot diagnose ADHD, their opinions are instrumental in decisions to send a child to be evaluated by a mental health professional, Elder said.

"Many ADHD diagnoses may be driven by teachers' perceptions of poor behavior among the youngest children in a kindergarten classroom," he said. "But these 'symptoms' may merely reflect emotional or intellectual immaturity among the youngest students."

Comments

Hmm. The assumption seems to be from the start that the numbers automatically mean misdiagnosis. Could it also be the case that children who are younger than their classmates are more likely to exhibit symptoms of ADHD earlier than they would otherwise?

I probably didn't express myself very clearly. What I meant was that the environment might be more bewildering or stimulating or even boring to a younger child, possibly influencing the expression of symptoms (which can vary considerably with the surroundings). Or it could well be immaturity as others have said. Anyway, just suggesting the possibility, mainly because I tend to start asking questions whenever a report says what people want to hear. That said, I have many qualms about the way ADHD is currently diagnosed and treated.

Another thought. Maybe someone should see if there's a correlation with whether a teacher and the student get along well. I was good as gold with teachers I liked and textbook ADHD with those who, shall we say, didn't impress me. Of course, in my day they didn't diagnose, they simply blamed the child. *sigh* So much ends up being different lyrics, same old tune.

Anyway, just suggesting the possibility, mainly because I tend to start
asking questions whenever a report says what people want to hear.

In part I would agree, but the flip side of that is that I'm more suspicious when only "outside" adults seem to see the symptoms. Parents are usually quite sensitive to abnormal behaviors in their children, so when a parent expresses surprise at such a diagnosis, it makes me question the diagnostician. While it is certainly true that some parents may be in denial, it is equally true that most teachers simply want to get through the day.

I agree one hundred percent with that. Today is a wonderful day my child's Dr. refused to medicate her YAY!!! The school system had done a IEP evaluation on her, can anyone guess the end result? ADHD combined type, I disagreed immediately. Then this school year started and i seen her struggling again (sigh). So i talked to her doctor about medicating her. (maybe i was wrong and in denial) So he done testing, spoke to the school ,had my childs teachers do the connors test. She didn't even come close to meeting the criteria. So my theory, I need to put my child in a different school system. One more thing if somebody tells you that you child is adhd request that they use the connors test.

Finally, someone voicing what I have been thinking for ages! :-) If you don't fit the norm you must be sick - you have ADHD CHILD! I'll give you some drugs (amphetamine no less), the norm-definers say.

Geez. Have the kids go climb trees or something that release energy and do not bore the wit out of them in the class room. That is good 'medicine' I should think. And a lot healthier. ;-)

Climbing trees sounds good to me, but don't tell the pharmaceutical companies though, there are hardly any forests left! Pharmaceutical companies don't like any naturally occurring non-patentable competition, such as fish oil for schizophrenia and psychosis, aspirin for headaches and blood-thinning and bio-identical hormones instead of HRT, and now trees for ADHD, etc.

So many people seem to be taking prescription drugs these days when there is often a natural, much cheaper, over the counter alternative. Highly addictive anti-depressants, tranquillisers and anti-psychotics are dished out like smarties to depressed or anxious people to either flood the brain with or inhibit reuptake of serotonin, dopamin etc. even though the long term consequences could be disastrous and may be linked to the big increases in neural disorders and dementia that are occurring. Often people are taking drugs which interact with eachother unfavourably but many doctors are not even aware of these drug interactive side-effects.

Prior to being diagnosed with Motot Neurone Disease (MND) my mother was prescribed Lipitor which is a cholesterol lowering drug that has been identified as having an increased incidence of MND occurring in people taking this drug. A warning was even issued by the World Health Organisaton, but it never occurred to my mother's doctor to stop prescribing the drug even when she had been diagnosed with MND.

Oil drilling companies such as BP have had some bad press lately and I would like to see more media exposure of how many of these massive, multinational companies have so much hidden power within our societies, because I believe that they are out of societies' control. Worse, still, they are controlling societies by donating huge sums to political parties, conducting advertising campaigns, discrediting or buying out their competitors etc.

I used to work for a massive multinational and it probably had more power than the UN, which isn't saying much of course. However, unlike the UN, the directors are not elected or representative of the people, yet they are able to swing elections and use vast amounts of money to make commercials that can indirectly result in the removal of democratically elected leaders, such as Kevin Rudd our now ex-Prime Minister of Australia, simply because he tried to put a tax on mining companies super profits that would have cost them billions!

The tax was not on their normal profits, it was on their super profits, which means that they were making massive profits at the Australian peoples' expense, by harvesting Australia's underpriced mining resources.

When Kevin Rudd threatened their super profits with a tax, they united and funded a series of paranoia inducing commercials, threatening the Australian public that their economy was under threat and that they would leave Australia if the tax remained, even though there were hundreds of companies who would have jumped at the opportunity of taking their places and their licences to mine here in Australia, and it was only their profits that were under threat.

My sentiments entirely, Bente!
My own thoughts, having had a child I was parenting diagnosed as needing treatment
When I went to the school and challenged the teacher who'd made the 'diagnosis' I was shocked at the distressed state of the teacher, herself!
Out of 37 children, apparently she thought/felt 6 of them had ADD/ADHD, and yes, they were the ones causing her the most problems - 'disturbing the lessons'
She then went into a dispowered rant about being prevented from doing anything else....'due to disciplinary restraints placed on teachers'
There's the rub! Discipline is such a confused area in and of itself, that one young lad I saw was standing on his desk shouting abuse at the top of his voice, whilst in the break between lessons.....and no comment was made
I may be old-fashioned, but that seems like a positive feedback to bad behaviour, not a need to drug children
It really annoys me that we have gotten into this state, and I feel sorry for the children, and would want to say to them, do not follow these poor examples......who will the future leaders be out of this generation, and what will their disciplines be???
PS: The child I was parenting had come from a broken marriage, had been put in a care home, where the children had been molested, yet she adjusted well, from being withdrawn and insecure, into a normally confident child, if a little scatty and chatty, when allowed to have fun, in a happy family setting
Aitch

Your comments made me remember my time in high school - the worst possible age when it comes to making trouble in class. :-)

We had this very strict teacher who managed to make everybody shut up and work properly in class, no matter how noisy they were in other contexts. We actually adored this teacher. And once he was confident everybody understood HE was the BOSS in the class room, he gave more 'room' to us and was in fact a very nice person being respected by all.

Whereas in other classes with other teachers we were disgusting monsters!

Most of the time I think it is as simple as that. Teachers need to rule in class, otherwise we have to start medicate all kids. hahaha

Admirable that you parented this child. I used to work at an orphanage when I was young. It takes so little to improve the lives of many of such unfortunate kids. Having a stable home to stay in (with any kind of family) may be what makes all the difference.

Yes.....terrible admission time:
My class had a groupthink geared to causing nervous breakdowns in teachers who exercised little or no control
A visit from the headmaster to find out where the teacher was....whilst the teacher was there was always a good breaktime celebration
I would probably have been a candidate for ADHD diagnosis and medication.....except it hadn't been invented yet - tee hee
Aitch

Kudos to Bente! I also have been on a private campaign for years against drugging our children. When my son started 2nd grade, I made a special request for him to be tested for the school's gifted program. The idiot who runs the program said he didn't make it because "testing" revealed he lacked motivation. In reality, he occasionally had times when he was a bit fidgety or talkative. Furthermore, she didn't possess the professional ability or patience to work with him. She also suggested that I take him to the doctor to be tested for ADHD. She said the wrong thing to a proud parent. I inquired if she had the medical background to make such a recommendation, which she didn't, and flat out told her it was irresponsible for her to make such a suggestion. My non-motivated son finished the year with straight A's in an accelerated class and finished third out of the entire 2nd grade in the Accelerated Reader program.

Parents need to be more pro-active in their kids' academic lives and our schools need to stop allowing teachers to make recommendations concerning medical treatment for children. Parents have gotten lazy and teachers have forgotten what their mission is. Overall, we need to remember that kids are kids and are not computerized. Our educational system needs a complete overhaul with more emphasis on understanding the psychology of children, with a greater appreciation for their individuality and uniqueness, rather than trying to train them to be little automatons.

And for any of you out there who want to counter my comments with smarmy, argumentative remarks, I will tell you in advance that we the parents are the front line in protecting our children from the "diagnosers," and need to be prepared to seek possible alternatives to traditional education. If nothing else, fight for your child and avoid the drugs.

Although teachers cannot diagnose ADHD, their opinions are instrumental
in decisions to send a child to be evaluated by a mental health
professional, Elder said.

I don't know what anyone else's view is but this statement is especially worrisome. While we can all agree that teachers cannot diagnose ADHD, it appears that mental health professionals can't either. With a potential 20% misdiagnosis rate, it would suggest that there is something seriously wrong with the "science" that is being applied here.

When a teacher recommended one of my kids be tested for ADHD, because she liked to talk to her friends and hugged a lot, the first question I asked was how many kids in the class were ADD already.

We have this cultural pap about creating independent, thinking, self-assured kids and then a large subset of society wants to homogenize and medicate kids, and it all involves people who make money from taxes. I say medicate the NEA.

This study doesn't surprise me at all. I have long believed (admittedly based on anecdotal evidence) that ADHD was being over-diagnosed. Perhaps we need to re-evaluate the criteria we're using to diagnose this disorder -- if this study's findings are correct and the disorder is being overdiagnosed (as I again suspect), we're medicating a lot of children unnecessarily...

Some children have behavioral issues due to maturity, age, lack of discipline, or problems at home but there are SOME children with real neurological disorders. It may manifest itself in withdrawn behavior or hyper behavior – it depends on the child. I like what Brain Balance has to say about the issue – http://www.brainbalancecenters.com . Strengthening brain communication through education, exercises, occupational therapy, etc. can make a big difference without drugs. I understand the difficult job that teachers have with 20 or more students who learn differently and at different levels. Never-the-less, it’s not as “easy” as every child with behavior or attention problems having ADHD. Some have sensory issues, etc.

Perhaps all these people diagnosing ADD\ADHD need to take a closer look at the famous experiments of David Rosenhan. That the opinion of teachers is relied upon so much seems extremely odd and concerning. Asking a teacher for an opinion, or even expecting them to identify potential "patients", is inducing bias in their observations if only because it is in a teacher's interest to get rid of the troublesome student and hey we've all been there with troublesome kids. Any excuse will do to deal with the problem. Yeah, he has ADD, fix it now!

In nearly 60 percent of cases, teachers are the first to suggest the ADHD diagnosis, though many teachers over-identify children at risk. In one study of teacher perceptions, 72 percent of teachers identified over 5 percent of their students as having ADHD, and fully one-third identified between 16 and 30 percent. The larger the classroom, the more likely a teacher was to overestimate the incidence of ADHD in her or his classroom.For more: http://neurolearning.com/EidesNewAtlantis.pdf

So, is there such thing as an accurate diagnosis? Does ADHD really exist as a "disability" ( or "illness" as my sons teacher suggested)? If there is an accurate diagnosis, how is that determined? Is it simply a label for a different learning ability, that doesn't fit well in a large classroom environment?

The reason why there are so many children with ADHD is because their parents have no idea how to parent. If a child cannot sit in one spot for 20 minutes by the age of five he/she either has a medical problem or there is a problem with the parenting style. Not every second of a person's life is exciting. There are mundane things that we all must do and children have to understand that or they will grow into very unhappy adults who will have great difficulty functioning in society. Teaching self control doesn't mean that a child will turn into a mindless drone. It helps the child reflect and think more deeply.
I do agree with this forum that ADHD is not something that a child needs to be medicated for IF the parents are willing to do the work at home. The problem is I have yet to meet a parent who would be willing to change their entire life for their child. The most common excuse is "I just can't do anything with him/.her" usually followed by a chuckle. Which basically means I'll continue to get into domestic disputes, bring a revolving door of "father/mother" figures into my child's life, drink myself into oblivion, allow my dead beat ex to make empty promises to my child etc. This also applies to those higher on the social strata who give their children everything BUT their time. This typical parent gives the child everything he/she wants because "it's not classy to confront my child in public which is where I always am since I am an "on the go" mom/dad" etc. They compete with their neighbors to have the most successful child when really what the kid needs is one on one time with mom and/or dad. I am not saying that parents shouldn't strive to provide the best for their child, but let's face it -very few become professional athletes, actors, rock stars etc.
Children need unstructured play and downtime. The schools do not permit this anymore thanks to lawsuits from parents who expect their children to go through childhood without ever experiencing a disappointment, minor physical injury etc. Playgrounds are an administrator's nightmare so most of the time their existence is strictly ornamental.
As a result of the competitive parenting that is taking place within our middle and upper class families, and the problems that plague the lower socio-economic parents, children today have no outlet for their stresses and lack the coping skills that are required to function in life. Most of them have been raised in daycares. A daycare cannot supply the one on one attention that a child would receive from a stay at home parent/grandparent. I know this isn't PC to say but it is true. The result is ADHD in those children whose core personalities cannot adapt to these changes in our society.

I agree that ADHD is misdiagnosed in alot of children and I agree that sometimes it has to do with parenting skills, I also agree with the person who said that sometimes its the teachers or people surrounding a child that makes them appear to have it. My Sons were Diagnosed with ADHD, I do medicate them but only for school, I changed thier life, by decreasing surgars, fatty foods and keepin them on a schedule, it really works. its just in school that they need the medication to focus, I know for a fact that they are not acting as ADHD because they are bored or dont like the settings at school because they both enjoy scholl. My ADHD of sons is not caused from bad parenting or any other thing, but because at ages 3 they both were exposed to lead in our houses and that is when they started acting up.